Summary Report for FSPSAs Initiated During the Report Period Center: 04
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 577 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 19 19 12.177776 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 12.177776 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
NURS -T1001 NURSING ASSESSMENT 1 1 1.571429 $78.5700 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.211111 $10.7800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.427778 $21.8400 $51.0500
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Subtotal (Total Children Is Unduplicated) 3 3 2.210318 $111.1900 $50.3000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 20 2.477775 $123.8800 $49.9900
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.355556 $33.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 2.605556 $130.2800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 6.285714 $314.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 2.966667 $74.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 8.002380 $400.1200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.088889 $4.4500 $50.0100
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.716667 $42.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 5.470635 $273.5400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 2.438889 $60.9700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.142857 $78.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 12 87.285713 $4364.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 443 470 3370.620608 $33706.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.428571 $387.8200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 11.000000 $785.8400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.285714 $130.7400 $57.2000
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Subtotal (Total Children Is Unduplicated) 464 555 3513.172191 $40911.9700 $11.6500
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Total 577 3527.560285 $41023.1500 $11.6300
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Number of Children (Unduplicated) With at Least One Authorization 482